Clinical manifestations:

Clinical features can be divided in to two groups

• Severe local pain at the site of sting radiating along with corresponding dermatomes without systemic involvement.
  
  
• Mild local pain or at times absent but present with severe systemic involvement
  
  

Local pain or benign sting
Sting by less poisonous scorpion species like Palmaneus Garvimanus (black scorpion) or scorpion with empty venom glands called telson are characterized by sudden onset of severe excruciating pain at the site of sting. Local sweating, swelling and fasciculation are seen over the part of sting. Due to severe pain victim tries to move the affected part of body (site of sting) just to find comfortable position but eventually fails. Subsequently pain radiates along the involved dermatomes. Simple taping over the stung part induces severe pain and withdrawal. Local swelling is often increased by repeated local injections. Many times, patient applies a tight tourniquet near the sting site or apply some herbal remedies or even burn the part of sting due to intolerable local pain. Because of severe pain patient is anxious, mild sweating or transient raised blood pressure with bradycardia can be noted, but there are no cold extremities or peripheral vasoconstriction or signs and symptoms suggestive of autonomic storm.

Systemic manifestations
The red scorpion venom is a potent sodium channels activator. Sting injects the venom in skin deep and stimulates the autonomic nervous system resulting in sudden pouring of catecholamines in to circulation. Both sympathetic and parasympathetic twigs are stimulated. But body is not at all prepared for such sudden accident as a result it responds randomly. Autonomic storm is characterized by initial parasympathetic stimulation clinically detected in form of vomiting once or twice, profuse sweating from all over the body, sweat literally flows for 7-17 hours (skin diarrhea), hyper-salivation for 2-12 hours, priapism for 6-18 hours, mydriasis, bradycardia (42-60 beats per minute), hypotension, transient ventricular premature beats with bigeminy pattern. Sympathetic stimulation is characterized by propped eyes, puffy and anxious face, oculo-gyric crisis, chest discomfort, perioral paresthesia at times tingling and numbness (paresthesia) all over body and cool extremities. Skin over hand and feet, palm and sole look like a washer-man hand i.e. fine wrinkles and cold. These changes occur simultaneously with parasympathetic stimulation but persist for long duration. Para-sternal systolic lift, transient systolic murmur of mitral regurgitation due to papillary muscle dysfunction due to coronary spasm is seen. Mild cases have little symptoms with cool extremities without severe sweating. The clinical manifestations at times are apparently diverse irrespective of similar pathology. Another clinically interesting finding observed is that on arrival, patients with these symptoms and signs have tolerable mild or at times absent local pain, but start getting severe intolerable pain as soon as there is improvement in peripheral circulation, warming of cool extremities, accompanied with clinical improvement.

Hypertension :

Patients can have raised blood pressure up to 210/160 mm hg with sinus bradycardia within 1-4 hours of sting. Children and occasionally adults with severe hypertension tend to be confused, agitated, at times have generalized convulsions, transient hemiplegia and oculogyric crisis. Bilateral extensor planter response, severe headaches, propped up eyes and puffy face are important diagnostic signs in children suggestive of hypertensive crisis. It is difficult to measure accurate blood pressure with routine sphygmomanometer in confused agitated child. Victim at times develops massive life threatening pulmonary edema with froth in mouth and nostril and intractable cough with hypertension.